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8. Foot and Ankle MCQs

Practice Set 215 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 4281

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains a midfoot injury after an axial load was applied to a plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals, with no associated fractures. What is the gold standard surgical treatment to limit the development of midfoot arthritis and maximize functional outcome in this strictly ligamentous injury?

. Closed reduction and percutaneous pinning of the first, second, and third tarsometatarsal joints
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Suture button fixation across the medial cuneiform and second metatarsal base alone
. Non-weight bearing short leg cast for 8 weeks

Correct Answer & Explanation

. Closed reduction and percutaneous pinning of the first, second, and third tarsometatarsal joints

Explanation

While Open Reduction and Internal Fixation (ORIF) has historically been the standard for Lisfranc injuries, level I evidence (such as the landmark study by Ly and Coetzee) has demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd tarsometatarsal joints) yields superior functional outcomes and a lower reoperation rate compared to ORIF specifically for strictly ligamentous Lisfranc injuries. ORIF remains the standard for purely bony or predominantly bony Lisfranc fracture-dislocations.

Question 4282

Topic: Ankle Trauma & Sports

A 28-year-old male sustains an acute high ankle sprain. Examination reveals a positive external rotation stress test and positive squeeze test. An MRI confirms an isolated full-thickness tear of the anterior inferior tibiofibular ligament (AITFL) and the interosseous membrane up to 5 cm proximal to the joint line. Intraoperatively, the syndesmosis is unstable to the hook test. If dynamic suture-button fixation is chosen over static syndesmotic screw fixation, what is an established clinical advantage?

. It requires routine removal prior to full weight-bearing
. It provides a rigid construct that completely restricts physiologic fibular rotation
. It allows for earlier return to weight-bearing and normal physiologic syndesmotic motion
. It is associated with higher rates of late diastasis and malreduction
. It eliminates the need for intraoperative fluoroscopic reduction assessment

Correct Answer & Explanation

. It requires routine removal prior to full weight-bearing

Explanation

Suture-button fixation for syndesmotic instability provides dynamic stabilization. Unlike static syndesmotic screws, the suture-button allows for normal, physiologic micro-motion (rotation and proximal-distal translation) of the fibula during the gait cycle. It also does not require routine removal and facilitates an earlier return to weight-bearing and functional activities. Current literature indicates equivalent or lower rates of malreduction compared to traditional screw fixation.

Question 4283

Topic: 8. Foot and Ankle

A 58-year-old male with poorly controlled type 2 diabetes and profound peripheral neuropathy presents with a red, hot, swollen right foot for 2 weeks. There are no skin breaks or ulcerations. He denies fever or chills. His WBC count is normal, and ESR is mildly elevated at 35 mm/hr. Radiographs demonstrate soft tissue swelling but no bony destruction, fragmentation, or subluxation.

What is the initial treatment of choice?

. Incision, drainage, and broad-spectrum intravenous antibiotics
. Open biopsy of the midfoot bones to rule out osteomyelitis
. Total contact casting and strict non-weight bearing
. Urgent midfoot arthrodesis with internal fixation
. Prescription for custom accommodative shoe wear and immediate weight-bearing as tolerated

Correct Answer & Explanation

. Incision, drainage, and broad-spectrum intravenous antibiotics

Explanation

The clinical presentation is classic for Eichenholtz stage 0 Charcot neuroarthropathy, characterized by a red, hot, swollen foot with normal or osteopenic radiographs but no distinct fragmentation or subluxation. The mainstay of treatment in the acute (Stage 0 or 1) phase of Charcot arthropathy is total contact casting (TCC) and strict non-weight bearing to arrest the progression of joint destruction until the acute inflammatory phase resolves (skin temperature equalizes with the contralateral limb).

Question 4284

Topic: Forefoot

A 50-year-old male presents with chronic dorsal pain in his first metatarsophalangeal (MTP) joint, exacerbated by walking. He has failed conservative management including a stiff-soled shoe with a Morton extension. X-rays reveal dorsal osteophytes and mild to moderate joint space narrowing primarily in the dorsal aspect of the joint, while the plantar joint space is preserved (Coughlin and Shurnas Grade 2). He desires to maintain motion. What is the most appropriate surgical intervention?

. First MTP joint arthrodesis
. Cheilectomy of the first MTP joint
. Keller resection arthroplasty
. Silicone implant arthroplasty
. First metatarsal corrective osteotomy (Scarf procedure)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Coughlin and Shurnas Grade 2 hallux rigidus presents with moderate osteophyte formation, dorsal joint space narrowing, and preserved plantar joint cartilage. Cheilectomy (removal of the dorsal osteophyte and the dorsal third of the metatarsal head) is the treatment of choice for Grade 1 and 2 hallux rigidus to relieve dorsal impingement and preserve motion. Arthrodesis is typically reserved for Grade 3 or 4 hallux rigidus (diffuse joint space loss). Keller arthroplasty is largely historical or reserved for elderly, low-demand patients due to the risk of transfer metatarsalgia and cock-up deformity.

Question 4285

Topic: 8. Foot and Ankle

A 31-year-old male falls from a ladder and sustains a Hawkins Type III talar neck fracture (fracture of the talar neck with subtalar and tibiotalar dislocation).

He is at high risk for avascular necrosis (AVN) of the talar body. Which of the following anatomical structures provides the majority of the blood supply to the talar body that is compromised in this injury?

. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branches of the posterior tibial artery
. Dorsalis pedis artery branches
. Perforating peroneal artery branches

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The talar body receives its blood supply from a retrograde extraosseous arterial ring. The largest and most significant contributor to the talar body's blood supply is the artery of the tarsal canal, which is a branch of the posterior tibial artery. The artery of the tarsal sinus (formed by branches of the dorsalis pedis and perforating peroneal) supplies the lateral aspect. The deltoid branches supply the medial aspect. A Hawkins III fracture disrupts all three major sources, leading to a near 100% risk of AVN.

Question 4286

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with progressive medial ankle pain and a new-onset flatfoot deformity. On examination, she has a flexible hindfoot, a 'too many toes' sign, and is unable to perform a single-leg heel rise. Weight-bearing radiographs reveal a flexible pes planovalgus deformity with >40% talonavicular uncoverage on the AP view, indicative of significant forefoot abduction. What is the most appropriate surgical management for this stage of posterior tibial tendon dysfunction (Stage IIb)?

. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer combined with a medializing calcaneal osteotomy
. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening
. Isolated talonavicular arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Isolated flexor digitorum longus (FDL) transfer to the navicular

Explanation

The patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible hindfoot deformity with significant forefoot abduction (>40% talonavicular uncoverage). While Stage IIa (minimal forefoot abduction) is effectively treated with an FDL transfer and medializing calcaneal osteotomy, Stage IIb requires the addition of a lateral column lengthening (such as an Evans osteotomy or calcaneocuboid distraction arthrodesis) to correct the forefoot abduction and restore the talonavicular joint alignment.

Question 4287

Topic: 8. Foot and Ankle

A 24-year-old male athlete sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 4 mm of diastasis between the bases of the first and second metatarsals without associated fractures. Which of the following treatments has been shown to provide the best long-term functional outcome and lowest reoperation rate for this specific injury pattern?

. Non-weight-bearing cast immobilization for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints
. Primary arthrodesis of all five tarsometatarsal joints

Correct Answer & Explanation

. Non-weight-bearing cast immobilization for 6 weeks

Explanation

For purely ligamentous Lisfranc injuries, multiple studies (such as those by Ly and Coetzee) have demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd tarsometatarsal joints) yields superior functional outcomes, higher return to pre-injury activity levels, and lower rates of subsequent surgeries for hardware removal or salvage arthrodesis compared to open reduction and internal fixation (ORIF).

Question 4288

Topic: Midfoot & Hindfoot

A 55-year-old man with a 15-year history of poorly controlled type 2 diabetes and profound peripheral neuropathy presents with a red, hot, swollen right foot. He denies trauma. He is afebrile with normal white blood cell count and inflammatory markers. Radiographs reveal fragmentation, periarticular debris, and subluxation of the midfoot joints. There are no skin ulcerations. What is the most appropriate initial management?

. Urgent open reduction and internal fixation of the midfoot
. Intravenous antibiotics and bone biopsy
. Midfoot arthrodesis with rigid internal fixation
. Total contact casting and non-weight bearing
. Below-knee amputation

Correct Answer & Explanation

. Urgent open reduction and internal fixation of the midfoot

Explanation

The patient's presentation is classic for an acute Charcot neuroarthropathy (Eichenholtz Stage 1 - Fragmentation). In the absence of an open ulcer or systemic signs of infection, the initial treatment is non-operative and consists of offloading to prevent further progressive deformity. A total contact cast (TCC) and strict non-weight bearing are the gold standards for managing acute Charcot arthropathy.

Question 4289

Topic: Forefoot

A 45-year-old woman presents with persistent forefoot pain and a prominent bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and notable hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to address her pathology?

. Distal chevron osteotomy
. Proximal opening wedge osteotomy with distal soft tissue realignment
. First tarsometatarsal joint arthrodesis (Lapidus procedure) with distal soft tissue realignment
. First metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a severe hallux valgus deformity (IMA > 15 degrees, HVA > 40 degrees) accompanied by first TMT joint hypermobility. A first TMT arthrodesis (Lapidus procedure) is the procedure of choice in this scenario, as it allows for large corrections of the IMA while simultaneously addressing the apex of the deformity and stabilizing the hypermobile medial column. Distal osteotomies are insufficient for IMA correction of this magnitude.

Question 4290

Topic: 8. Foot and Ankle

A 40-year-old construction worker falls from a ladder and sustains a displaced, intra-articular calcaneus fracture. He undergoes open reduction and internal fixation utilizing an extensile lateral approach. Which of the following is the most common complication associated with this specific surgical approach?

. Sural nerve neuroma
. Superficial peroneal nerve injury
. Post-traumatic subtalar arthritis
. Flexor hallucis longus tendon entrapment
. Wound edge necrosis and dehiscence

Correct Answer & Explanation

. Sural nerve neuroma

Explanation

The extensile lateral approach to the calcaneus is notorious for soft tissue complications. Wound edge necrosis, dehiscence, and subsequent infection are the most common complications, occurring in approximately 10% to 25% of cases. The risk is minimized by creating a full-thickness 'no-touch' flap, respecting the vascular supply from the lateral calcaneal artery, and delaying surgery until the 'wrinkle sign' appears.

Question 4291

Topic: 8. Foot and Ankle

A 30-year-old man undergoes open reduction and internal fixation for a Weber C ankle fracture with syndesmotic instability. The syndesmosis is stabilized with two 3.5-mm metallic screws crossing four cortices. Postoperatively, he recovers well and begins weight-bearing at 6 weeks. According to current orthopedic literature, what is the recommendation regarding the routine removal of metallic syndesmotic screws in asymptomatic patients?

. Routine removal at 6 weeks is mandatory to prevent permanent restriction of ankle dorsiflexion
. Routine removal is generally not indicated, as retained or broken screws do not significantly worsen clinical outcomes
. Routine removal at 12 weeks is required to prevent screw breakage
. Removal is mandatory if screws break, as broken hardware strongly correlates with functional decline
. Routine removal at 1 year is recommended to prevent late syndesmotic diastasis

Correct Answer & Explanation

. Routine removal at 6 weeks is mandatory to prevent permanent restriction of ankle dorsiflexion

Explanation

Current literature supports that routine removal of metallic syndesmotic screws is not necessary in asymptomatic patients. Studies have shown that functional outcomes do not significantly differ between patients who have their screws removed and those who retain them, even if the screws break or loosen. Retained hardware only requires removal if it causes localized pain or irritation.

Question 4292

Topic: 8. Foot and Ankle

A 24-year-old professional football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show a 2.5 mm diastasis between the base of the first and second metatarsals. MRI confirms a purely ligamentous disruption of the Lisfranc complex without associated fractures. What is the most appropriate definitive management to minimize reoperation rates and maximize functional outcome in this athlete?

. Non-weight-bearing in a short leg cast for 6 weeks
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating without joint decortication
. Dynamic stabilization with suture button fixation alone

Correct Answer & Explanation

. Non-weight-bearing in a short leg cast for 6 weeks

Explanation

For purely ligamentous Lisfranc injuries, multiple randomized controlled trials (such as Ly and Coetzee) have demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in superior short- and medium-term functional outcomes and significantly lower reoperation rates compared to ORIF. ORIF is typically preferred for bony Lisfranc fracture-dislocations to preserve joint motion, but purely ligamentous injuries have a high rate of hardware failure and post-traumatic arthritis when treated with ORIF.

Question 4293

Topic: 8. Foot and Ankle

A 34-year-old woman presents with bilateral foot pain, lateral column overload, and frequent ankle sprains. Examination shows a bilateral cavovarus foot type. To evaluate the flexibility of the hindfoot, you perform a Coleman block test. When the patient stands with her heel and lateral border of the foot on the block and the first metatarsal suspended freely off the block, her hindfoot varus corrects entirely to neutral. What does this physical examination finding indicate?

. The varus deformity is primarily driven by a rigid, plantarflexed first ray
. The hindfoot varus is a fixed, rigid deformity requiring a triple arthrodesis
. The deformity is secondary to a fixed contracture of the Achilles tendon
. There is a fixed subtalar joint contracture
. The deformity is compensatory for weakness of the peroneus brevis

Correct Answer & Explanation

. The varus deformity is primarily driven by a rigid, plantarflexed first ray

Explanation

The Coleman block test evaluates the flexibility of the hindfoot in a cavovarus deformity. If suspending the first ray (dropping it off the block) allows the hindfoot to correct to neutral, the hindfoot is flexible. This indicates that the hindfoot varus is a compensatory, non-fixed deformity driven by a rigidly plantarflexed first ray. Treatment should therefore focus on correcting the forefoot (e.g., first metatarsal dorsiflexion osteotomy) rather than fusing the hindfoot.

Question 4294

Topic: 8. Foot and Ankle

A 52-year-old man presents with chronic weakness in his posterior ankle 4 months after feeling a 'pop' while playing tennis. He has a palpable gap 6 cm proximal to the calcaneal insertion of the Achilles tendon. MRI confirms a chronic Achilles tendon rupture with a 5.5 cm gap with the foot in resting equinus. Which of the following is the most appropriate surgical treatment?

. End-to-end repair with heavy nonabsorbable suture
. V-Y fascial advancement and direct end-to-end repair
. Flexor hallucis longus (FHL) transfer with or without V-Y advancement
. Flexor digitorum longus (FDL) transfer alone
. Isolated gastrocnemius recession

Correct Answer & Explanation

. End-to-end repair with heavy nonabsorbable suture

Explanation

Chronic Achilles ruptures with a gap of greater than 5 cm typically cannot be repaired end-to-end, even with V-Y fascial advancement alone. An FHL transfer is the procedure of choice for large defects (> 3-5 cm). The FHL provides well-vascularized tissue to bridge the gap, has an in-phase firing pattern with the Achilles, and supplies supplemental plantarflexion power.

Question 4295

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressively worsening right foot pain. On examination, she has a flexible flatfoot, a positive 'too-many-toes' sign, and an inability to perform a single-limb heel raise. Radiographs reveal uncovering of the talonavicular joint of 45% indicating severe forefoot abduction. What is the most appropriate surgical treatment algorithm for this stage of adult acquired flatfoot deformity?

. Isolated subtalar arthrodesis
. Spring ligament repair and isolated gastrocnemius recession
. FDL transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and a lateral column lengthening
. Triple arthrodesis

Correct Answer & Explanation

. Isolated subtalar arthrodesis

Explanation

This patient presents with Stage IIb adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIb is characterized by a flexible hindfoot (Stage II) but with significant forefoot abduction (typically >30-40% talonavicular uncoverage). Treatment requires an FDL transfer, a medial displacement calcaneal osteotomy (MDCO) to restore the heel axis, AND a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid fusion) to specifically correct the severe forefoot abduction. Triple arthrodesis is reserved for rigid (Stage III) deformities.

Question 4296

Topic: 8. Foot and Ankle

A 58-year-old man with poorly controlled type 2 diabetes presents with a red, hot, swollen left foot. He reports no trauma. Radiographs show soft tissue swelling but no acute fractures, dislocations, or bony destruction. Inflammatory markers are mildly elevated. He is diagnosed with acute Eichenholtz stage 0 Charcot neuroarthropathy. What is the most appropriate initial management?

. Urgent surgical debridement and culture
. Open reduction and internal fixation of the midfoot
. Total contact casting and non-weight-bearing
. Custom orthotic shoe wear with a rocker bottom sole
. Intravenous antibiotics for 6 weeks

Correct Answer & Explanation

. Urgent surgical debridement and culture

Explanation

Acute (Eichenholtz Stage 0 or I) Charcot neuroarthropathy presents with a red, hot, swollen extremity that mimics infection. Radiographs in Stage 0 may be normal or show only soft tissue swelling. The mainstay of treatment in the acute phase is strict offloading to prevent progressive deformity and devastating bone destruction. This is most effectively achieved with a total contact cast (TCC). Surgery is generally contraindicated in the acute inflammatory phase unless there is an unstable deformity causing impending soft tissue compromise.

Question 4297

Topic: Forefoot

A 42-year-old woman presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination reveals profound hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. What is the most appropriate surgical procedure?

. Distal chevron osteotomy
. Modified McBride procedure
. First metatarsophalangeal (MTP) joint arthrodesis
. Proximal metatarsal osteotomy or Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

This patient has severe hallux valgus (HVA >40 degrees, IMA >15 degrees) combined with first TMT hypermobility. A distal osteotomy (Chevron) cannot adequately correct a large IMA of 18 degrees. The Lapidus procedure (first TMT arthrodesis) is highly effective for large IMA corrections and uniquely addresses the TMT hypermobility. A proximal osteotomy is also an option for severe deformities without hypermobility, but Lapidus is the classic choice when hypermobility is present.

Question 4298

Topic: 8. Foot and Ankle

A 40-year-old male sustains a displaced intra-articular calcaneus fracture. He undergoes open reduction and internal fixation via an extensile lateral approach. Which of the following technical factors or patient characteristics most significantly increases his risk of postoperative wound necrosis and deep infection?

. Waiting 10-14 days for the 'wrinkle sign' to appear before surgery
. Use of a full-thickness 'no-touch' subperiosteal flap technique
. Smoking 1 pack of cigarettes per day
. Placing the vertical limb of the incision directly between the fibula and Achilles tendon
. Using a closed suction drain postoperatively

Correct Answer & Explanation

. Waiting 10-14 days for the 'wrinkle sign' to appear before surgery

Explanation

Smoking is the single most significant modifiable patient risk factor for wound healing complications following the extensile lateral approach for calcaneus fractures, increasing the risk of wound necrosis and infection by up to 3 to 4 times. Waiting for the wrinkle sign (decreased swelling), using a full-thickness 'no-touch' subperiosteal flap, and proper incision placement are all standard techniques explicitly used tominimizethe risk of wound complications.

Question 4299

Topic: 8. Foot and Ankle

A 25-year-old female sustains a severe midfoot sprain after a fall from a horse. Weight-bearing radiographs show a 4 mm diastasis between the base of the first and second metatarsals. MRI confirms a purely ligamentous Lisfranc injury with complete disruption of the Lisfranc ligament. Compared to open reduction and internal fixation (ORIF), primary arthrodesis for this specific injury pattern is associated with which of the following?

. Higher rate of post-traumatic osteoarthritis in adjacent joints
. Lower rate of planned secondary surgeries
. Increased risk of nonunion
. Inferior functional outcomes at 1 year
. Higher risk of hardware failure

Correct Answer & Explanation

. Higher rate of post-traumatic osteoarthritis in adjacent joints

Explanation

Purely ligamentous Lisfranc injuries are notoriously unstable and have a high rate of post-traumatic arthritis and hardware failure when treated with ORIF. Studies (such as Coetzee et al.) have shown that primary arthrodesis of the medial columns (first, second, and third tarsometatarsal joints) for purely ligamentous injuries results in lower rates of planned secondary surgeries (such as hardware removal) and comparable or slightly better functional outcomes compared to ORIF.

Question 4300

Topic: 8. Foot and Ankle

A 28-year-old male sustains a Hawkins Type II talar neck fracture following a motor vehicle collision. The primary blood supply to the talar body is at significant risk for disruption. Which of the following vessels provides the majority of the blood supply to the talar body?

. Artery of the sinus tarsi
. Artery of the tarsal canal
. Deltoid branches of the posterior tibial artery
. Dorsalis pedis artery
. Medial plantar artery

Correct Answer & Explanation

. Artery of the sinus tarsi

Explanation

The major blood supply to the talar body is the artery of the tarsal canal, which is a branch of the posterior tibial artery. The artery of the sinus tarsi, derived from the perforating peroneal and dorsalis pedis arteries, provides a secondary supply. The deltoid branches supply the medial aspect of the body. In a Hawkins II fracture (talar neck fracture with subtalar dislocation), the artery of the tarsal canal is frequently disrupted, placing the talar body at risk for avascular necrosis.

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